Florida State University

Subrecipient Conflict of Interest Disclosure Form for the

Environmental Protection Agency (EPA)

In order to comply with theEnvironmental Protection Agency’s Final Financial Assistance Conflict of Interest Policy, all Subrecipientsmust complete this form when submitting a proposal to Florida State University to receive EPA pass-through funding.Definitions may be found in EPA’s Policy; however, the following are important to reiterate:

  • Conflict of Interest (COI): An actual or potential situation that undermines, or may undermine, the impartiality of an individual or non-Federal entity because their self-interest conflicts, or may conflict, with their duty and obligations to EPA and the public in performing an EPA financial assistance agreement. The term also includes situations that create, or may create, an unfair competitive advantage, or the appearance of such, for an applicant in competing for federal financial assistance from EPA.
  • Immediate Family:Family members include one party with any of the following relationships to another party: spouse, and parents thereof; children, and spouses thereof; parents, and spouses thereof; siblings, and spouses thereof; grandparents and grandchildren, and spouses thereof; domestic partner and parents thereof, including domestic partners of any individual listed in this definition; and any individual related by blood or affinity whose close association with the employee is the equivalent of a family relationship.

FSU defines Investigatoras anyone, regardless of position or title, who is responsible for the design, conduct, or reporting of research.

1. / Subrecipient Name:
SubrecipientPI:
FSU PI:
FSU Project Title:
2. / Conflict of Interest Certification and Reports:
By accepting a subaward and spending EPA funds, Subrecipient certifies that:
  1. It will comply withFinal Financial Assistance Conflict of Interest Policy.
  2. It will submit the following reports in accordance with the due date:

Report Type / Description / Due
1. / Initial Report: Any Investigator COI and management plan / To be submitted on this form; see# 3 below.
2. / Subsequent Report: Any COI subsequently identified after initial report / Within 5 days of identification
  1. No EPA employee participated in the development of this proposal or otherwise provided advice to Subrecipient Investigators on how to write a proposal with the exception of advice regarding whether the applicant or project was eligible for funding.
Reports must describe the conflict of interest and include information regarding measures Subrecipient will make or has made to eliminate, neutralize, mitigate or otherwise resolve the COI prior to expenditure of EPA funds.Reports are to be emailed toFSU’s Director of Research Compliance Programs (ORCP) with the subject line “Subrecipient EPA COI Report”.If the Subrecipient does not discover a COI during an inquiry, no report is required.
3. / Initial COI Report(Required; check ONE of the following options)
Subrecipientcertifies that there is currently no conflict of interestfor any Subrecipient Investigator, and agrees to notify FSU’s ORCPof any subsequently identified COI within 5 days of identification.
OR
Subrecipient certifies that the attached COIdisclosure(s) and mitigation report)(s)for applicableSubrecipient Investigators is/arecomplete and current, and agrees to notify FSU’s ORCP of any subsequently identified COI within 5 days of identification.
4. / Signature ofSubrecipient’s Authorized Official
Printed Name / Signature / Date

Subrecipient EPA COI Form 11/06/15